NP Location Service Sign-up

Sign-Up for the NP Location Service

Personal Information
Bold, red items are required. Unbold, green items are requested.
Name:		First, middle and last names. Please include a period (.) after a first or middle initial.
Credentials:		These will follow your name in directory. Please do not use punctuation. Suggested format is Highest degree then licensure then other. Example: MSN ARNP FAAN. This field has 15 characters allowed.
Nick Name:		If you like to use a nick name you can include it here.
Year graduated:		Year of graduation from NP, CNM or CRNA program. Use 4 digit year (2000).
Type of NP program:
Highest earned degree:
Gender:
Certified Specialty:
Certifying Body:

Practice Information (This information will be available for viewing on the web)
Please enter information about your practice exactly as you would like it to appear. Bold, red items are required. Unbold, green items are requested.
Practice Name:		Enter the name of your practice.
Physical Address:		This is the address you give to your clients when they want to come and see you.
Postal Address:		Use this only if your mailing address is different from the above address. An example would be PO Box 123
City / State / Zip:
County / Country:
Phone / Fax:		Please use the format 999.999.9999 X-9999
Specialty:		Select the predominant choices for your practice or add a new specialty.
New Specialty:
Email:		Required so directory administrator can reach you. Not required to allow any other use.

Professional Status Information
The information below will not be released to consumers. It will be used to try to identify and correct duplicate entries, to resolve other administrative issues and selectively for research. Bold, red items are required. Unbold, green items are requested.
Practice Status:
Prior Name:
Date of Birth:
Can you prescribe medications:
Mail Preferences:	No restrictions at this time Do not send CE information Do not send Employment information Do not send NP organization information Do not send Product information Do not send Legislative information Don't send any information	Select as many choices as appropriate.

Enter a User Name and Password so that you can come back and update your information at anytime.
User Name:	Password: